Laparoscopic ultrasound for the detection of hepatic metastases during laparoscopic colorectal cancer surgery

PURPOSE: The search for liver metastases before surgery forms an accepted part of colorectal cancer surgical practice. Intraoperative ultrasound and manual palpation of liver together form the criterion standard as far as screening for metastases is concerned. However, extracorporeal imaging, such as ultrasound and magnetic resonance imaging, are also widely used. The purpose of this study was to demonstrate the efficacy of laparoscopic ultrasound scan in detection of liver metastases during laparoscopic colorectal cancer surgery by comparison with conventional imaging modalities. METHODS: A prospective, controlled study was undertaken. A total of 76 consecutive patients undergoing laparoscopic colorectal resections for malignancy were recruited. Patients underwent preoperative liver ultrasound scan and intraoperative blinded laparoscopic ultrasound scan examination performed by a single surgeon. Contrast-enhanced magnetic resonance imaging was performed within 30 days of surgery. RESULTS: Conventional ultrasound scan was negative in all cases. Metastases were identified during simple laparoscopic inspection of the liver in one case. Two cases shown by laparoscopic ultrasound scan to have definite metastases were confirmed by magnetic resonance imaging. In seven further instances laparoscopic ultrasound scan identified suspicious liver masses. In three cases these were confirmed to be metastases at magnetic resonance imaging; one was confirmed as a cyst, and the remaining three suspicious lesions were confirmed at serial magnetic resonance imaging scans to be benign and of no significance. CONCLUSION: Laparoscopic ultrasound scan with a flexible-tipped probe permits satisfactory hepatic examination. It is superior to conventional ultrasound scan and seems to be as effective as magnetic resonance imaging, although the latter modality is still required to delineate identified lesions.J. E. Hartley and H. Kumar were supported by Autosuture UK. Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Long-term survivors of colorectal cancer with unresectable hepatic metastases

Five patients with colorectal cancer and unresectable synchronous liver metastases have survived for over five years at this writing. Four of the five had multiple metastases over both lobes, as diagnosed preoperatively, and the other had multiple metastases in the right lobe not evident preoperatively. The primary foci were excised completely in four patients. For one patient with multiple metastases limited to the right lobe, the postoperative cancer chemotherapy prescribed was intravenous mitomycin C (MMC; 12 mg) and oral ftorafur (a derivative of 5-FU) for a total dose of 291 gm over 63 weeks. The remaining four patients underwent postoperative intra-arterial infusion therapy with the average total dose of 20.5 mg of MMC plus 5600 mg of 5-FU; subsequently, they received protracted chemotherapy with oral ftorafur of 354 gm as an average, with little or no side effects. In these four patients, duration of intra-arterial treatment was an average of 3.2 weeks, and the subsequent oral treatment continued for an average of 85 weeks. Recent hepatic echography and CEA determinations show these patients to be free from intrahepatic metastasis.     

Treatment of colorectal cancer hepatic metastases by hepatic artery chemotherapy

Our clinical experience with 69 patients with metastatic colorectal cancer to the liver treated with hepatic artery chemotherapy is reviewed. All patients have had a minimum of six months follow-up. The Infusaid^® implantable drug delivery system was used by direct laparotomy in one third, and via the transaxillary approach in the remaining two thirds. Two thirds of the patients had at least 25 percent of the liver replaced with tumor. Chemotherapeutic agents included FUdR, mitomycin C, and BCNU. The overall response rate was 51 percent and 69 percent for the three-drug combination. Efficacy was not different in patients who had received prior systemic fluorouracil. Median survival from start of hepatic artery chemotherapy was one year.     

Detection of hepatic metastases from colorectal carcinoma: comparison of histopathologic features of anatomically resected liver with results of preoperative imaging

GOALS: The specificity and sensitivity of intravenous-enhanced multidetector row computed tomography (MDCT), superparamagnetic iron oxide-enhanced magnetic resonance imaging (SPIO-MRI), multidetector row computed tomography with arterioportography combined with multidetector row computed tomography with hepatic arteriography (CTAP/CTHA), and intraoperative ultrasonography (IOUS) for detecting hepatic metastases from colorectal carcinoma were evaluated based on histopathologic examination of resected livers. STUDY: MDCT, SPIO-MRI, CTAP/CTHA, and IOUS were performed routinely to determine surgical indications and methods in patients with hepatic metastases from colorectal carcinoma. The resected liver specimens were then cut serially into sections 3 to 5 mm thick for routine histologic examination. RESULTS: Fifty metastatic lesions were detected by histopathologic study of a large amount of anatomically resected liver from 8 patients with colorectal liver metastasis. The tumors ranged in size from 3 to 53 mm (mean 13.8 mm) and 26 lesions (52%) were less than 10 mm in diameter. Histopathologic examination of the resected liver specimens showed that CTAP/CTHA was the most sensitive imaging modality, followed in order by IOUS, SPIO-MRI, and MDCT. Among all the tumors detected by CTAP/CTHA, SPIO-MRI overlooked 5, but all of the tumors detected by SPIO-MRI were also detected by CTAP/CTHA. The number of metastatic liver tumors detected differed significantly among MDCT, SPIO-MRI, and histopathologic examination. One false-positive lesion was detected by IOUS. CONCLUSIONS: CTAP/CTHA is a useful preoperative imaging modality for detecting small hepatic metastases from colorectal carcinoma.     

In vitro detection of occult bone marrow metastases in patients with colorectal cancer hepatic metastases

PURPOSE: The purpose of this study was to assess the immunocytochemical status of bone marrow aspirates from patients with clinically isolated hepatic metastases to test the hypothesis that such findings would allow improved patient selection for liver-directed treatment. METHODS: All patients had biopsy-proven or presumed colorectal cancer metastatic to the liver and were scheduled for an operative procedure for hepatic resection or for hepatic artery catheter and chemotherapy pump implant. Immunocytochemical analysis of bone marrow aspirate smears was performed with a panel of monoclonal antibodies directed toward cytokeratins, Lewis Y antigen and A-33 colorectal epitopes. RESULTS: Data from 80 patients indicated that bone marrow reactivity was present in 9.5 percent of those with resectable hepatic metastases and in 34 percent of those not resected (P=0.03). No single monoclonal antibody or combination produced better discrimination. CONCLUSIONS: Presence or absence of presumed occult colorectal cancer cells in the bone marrow of patients with isolated hepatic metastases is biologically interesting, but not useful in selecting or altering patient management.Supported in part by the Ludwig Institute.     

Intraoperative ultrasonography in detection of hepatic metastases from colorectal cancer

PURPOSE: This study was designed to compare diagnostic accuracies of measuring liver enzymes, preoperative ultrasonography, surgical examination, and intraoperative ultrasonography for detection of liver metastases from colorectal cancer. METHODS: Blind, prospective comparisons of diagnostic examinations mentioned above were performed in 295 consecutive patients with colorectal cancer. An experienced ultrasonologist performed the preoperative examinations, nd results were unknown to the other experienced ultrasonologist who performed the intraoperative examinations. The latter, also was unaware of the findings by the surgeon. The presence of metastases was further assessed by ultrasonography three months postoperatively, as well as additional surgery and liver biopsy in some of the patients. RESULTS: The sensitivity of intraoperative ultrasonography (62/64) was significantly superior to that of surgical exploration (54/64) and that of preoperative ultrasonography (45/64). The lowest sensitivity was presented by liver enzymes. Bilobar metastases were detected in 42 of 46 patients by intraoperative ultrasonography but in only 33 patients by the surgeon. Intraoperative ultrasonography demonstrated the highest specificity of all examinations. CONCLUSIONS: Intraoperative ultrasonography reduces the number of patients with liver metastases from being subjected to superfluous or even harmful liver surgery, and it may increase the number in whom liver surgery will prolong life.Dr. Rafaelsen was supported by grants from The Danish Cancer Society and the Albani Foundation.Presented at the 7th Congress of World Federation for Ultrasound in Medicine and Biology, Sapporo, Japan, July 17 to 22, 1994.     

Criteria for the selective use of contrast-enhanced intra-operative ultrasound during surgery for colorectal liver metastases

Background

Contrast-enhanced intra-operative ultrasound (CE-IOUS) for colorectal liver metastases (CLMs) has become a part of clinical practice. Whether it should be selectively or routinely applied remains unclear. The aim of this study was to define criteria for the use of CE-IOUS.

Methods

One-hundred and twenty-seven patients underwent a hepatectomy for CLMs using IOUS and CE-IOUS. All patients underwent computed tomography (CT) and/or magnetic resonance imaging (MRI) within 2 weeks prior to surgery. The reference was histology, and imaging at 6 months after surgery. Univariate and multivariate analyses were performed. Statistical significance was set at P = 0.05.

Results

Using IOUS an additional 172 lesions in 51 patients were found. CE-IOUS found 14 additional lesions in 6 patients. Seventy-eight CLMs in 38 patients appeared within 6 months after surgery. The sensitivity, specificity, positive- and negative-predictive value were 63%, 98%, 100% and 27% for pre-operative imaging, 87%, 100%, 100% and 52% for IOUS, and 89%, 100%, 100% and 56% for IOUS+CE-IOUS, respectively. CE-IOUS allowed better tumour margin definition in 23 patients (18%), thus assisting resection. Analyses indicated that the presence of multiple (P = 0.014), and isoechoic CLMs (P = 0.049) were independently correlated with new findings at CE-IOUS.

Conclusions

Compared with IOUS, CE-IOUS improved detection and resection guidance. These additions are significant and demand its use in cases with multiple and isoechoic CLMs.     

肝肿瘤微创切除术治疗结直肠癌肝转移患者效果研究

目的 比较开腹与腹腔镜下微创肿瘤切除术治疗结直肠癌肝转移患者的疗效。方法 2011年2月~2014年8月我科收治的82例结直肠癌肝转移患者,行开腹手术切除治疗38例,经腹腔镜下肝肿瘤微创切除术治疗44例。术后常规行影像学检查随访。结果 术后两组患者均未出现围术期死亡,两组出现白细胞下降、消化道反应、乏力、手脚麻木、肝区疼痛、发热、黄疸、腹腔积液等不良反应,部分不良反应有显著差异;术后第7 d和14 d,两组血清AST、ALT均先升高后降低,血清白蛋白和胆碱酯酶均降低,差异无统计学意义（P>0.05）;腹腔镜手术组患者1 a、2 a和3 a生存率分别为86.4%、47.7%和38.6%,开腹组分别为71.0%、42.1%和34.21%,也无显著性差异（P>0.05）。结论 采用腹腔镜下肝肿瘤微创切除术治疗结直肠癌肝转移患者效果较好,但对患者全身情况要求较高,手术技巧需娴熟,其在这类患者治疗中的应用还需要继续观察。     

Repeat hepatectomy for recurrent hepatic metastases from colorectal cancer.

BACKGROUND/AIMS: Resection of liver metastases from colorectal cancer is accepted as a safe, and curative treatment. Furthermore, repeat hepatectomy has been indicated for hepatic recurrence after initial hepatectomy to achieve long-term survival or cure. The present study is a retrospective review of our results using repeat hepatectomy for colorectal liver metastases to identify outcomes and prognostic factors associated with long-term survival. METHODOLOGY: Ninety-four patients underwent an initial hepatectomy for colorectal metastases between 1990 and 1995. Thirty patients had hepatic recurrence after the initial hepatectomy. Eleven patients underwent repeat hepatectomy for isolated hepatic recurrence. RESULTS: The operative mortality was 0%. The overall 5-year survival rate after detection of second liver metastases of 11 patients was 45.5%. The distribution of first liver metastases and disease-free interval between the first and second hepatectomy demonstrated significance in relation to survival after repeat hepatectomy (P = 0.0303 and 0.0338). CONCLUSIONS: Repeat hepatectomy for recurrent liver metastases from colorectal cancer was the most effective treatment to improve survival time for selected patients. In patients with isolated second liver metastasis, unilateral spread of first liver metastases, and a disease-free interval between the first and second hepatectomies of more than 12 months, long-term survival or cure can be expected after repeat hepatectomy.     

Perioperative chemotherapy and liver resection for hepatic metastases of colorectal cancer

Surgical resection has played a major role in the treatment for colorectal liver metastases. The safety and efficacy of surgery for liver metastasis are obvious, although there are some differences between the western countries and Japan concerning the surgical indication, procedures, timing of chemotherapies in a perioperative period, and treatment of a primary disease. In future, long-term outcomes after surgical resection for colorectal liver metastases would be expected to be prolonged by combination of surgery and chemotherapies.     

Laparoscopic resection of hepatic colorectal metastases

BackgroundLiver resection for secondary malignancy has become the standard of care in appropriately staged patients, offering 5-year survival rates of >40%. Reports of laparoscopic liver resection have been published with increasing frequency over the last few years. In these small series approximately one-third of all operations have been for malignancy, but survival figures cannot be assessed yet.MethodsA retrospective review of all laparoscopic liver resections performed by four surgeons in Brisbane between 1997 and 2004 was done. Follow-up was by regular patient review and telephone confirmation.ResultsOf 84 laparoscopic liver resections, 33 (39%) were for malignancy; 28 of these were for metastases (22 colorectal). Thirteen patients had left lateral sectionectomy with minimal morbidity; nine right hepatectomies were attempted and six cases of segmental or subsegmental resection were performed. Survival rates in 12 patients followed for 2 years with colorectal secondaries were 75% with 67% disease-free.DiscussionLaparoscopic liver resection is feasible in highly selected cases of malignant disease. Patients need to be appropriately staged and surgeons need a broad experience of open liver surgery and advanced laparoscopic procedures.     

Ornithine decarboxylase activity in hepatic and extrahepatic metastases from colorectal cancer

The values of ornithine decarboxylase (ODC) activity in hepatic and extrahepatic metastases from primary colorectal cancer were studied. Adjacent noninvolved tissue was used as a control. Liver metastases had significant elevated ODC levels over surrounding liver (0.271 vs. 0.065, respectively, P less than .008). Results similar to those found in liver metastases were noted in extrahepatic metastases (median value, 0.271). This study discusses the possible reasons for these elevations and emphasizes that these differences may have potential roles in the areas of diagnosis, staging, monitoring of the disease, and therapeutic interventions in colorectal cancer and its hepatic and extrahepatic metastases.     

Prognostic factors following liver resection for hepatic metastases from colorectal cancer

BACKGROUND/AIMS: We aimed to identify prognostic factors that may allow better patient selection for liver resection for colorectal liver metastases. METHODOLOGY: A retrospective analysis of the files of 120 patients undergoing liver resection for colorectal metastases between 9/85 and 12/96 was performed. Survival and disease-free survival were calculated, and a uni- and multivariate analysis for the prognostic impact of various perioperative factors on survival was performed. RESULTS: Perioperative morbidity and mortality were 28.3% and 5.8% respectively. Median overall survival was 30 months with a 5-year survival rate of 31%. Radicality was the prime prognostic determinant. In patients with R0-resection, a liver metastasis of > 3.5 cm in diameter was the only independent factor associated with an adverse prognosis. CONCLUSIONS: Liver resection for colorectal liver metastases should be attempted if complete resection with clear margins is feasible and may be especially beneficial in patients with small (< or = 3.5 cm) lesions.     

Prognostic factors following liver resection for hepatic metastases from colorectal cancer

AIM: To determine the impact of prognostic factors on survival of patients with metastases from colorectal cancer that underwent liver resection. METHODS: The records of 28 patients that underwent liver resection for metastases from colorectal cancer between April 1992 and September 2001 were retrospectively analyzed. Thirty-eight resections were performed (more than one resection in eight patients and two patients underwent re-resections). The primary tumor was resected in all the patients. A screening protocol for liver metastases including clinical examinations every three months, ultrassonography and CEA level until 5 years of follow-up and after every 6 months, was applied. The prognostic factors analyzed regarding the impact on survival were: Dukes C stage of primary tumor, size of metastasis >5 cm, a disease-free interval from primary tumor to metastasis < 1 year, CEA level > 100 ng/mL, resection margins < 1 cm and extrahepatic disease. The Kaplan-Meier curves, log rank and Cox regression were used for the statistical analysis. RESULTS: Perioperative morbidity and mortality were 39.3% and 3.6%, respectively. The 5-year survival rate was 35%. The independent prognostic factors were: disease-free interval from primary tumor to metastasis < 1 year and extrahepatic disease. CONCLUSIONS: The liver resection for metastases from colorectal cancer is a safe procedure with more than 30% 5-year survival. Disease-free interval from primary tumor to metastasis < 1 year and extrahepatic disease were independent prognostic factors.     

Bile carcinoembryonic antigen levels and occult hepatic metastases from colorectal cancer

PURPOSE: Up to 30 percent of patients will have occult hepatic metastases at the time of curative surgery for colorectal cancer. The ability to predict this group of patients would allow better targeting of appropriate therapy. It has been shown previously that patients with overt hepatic metastases have significantly high levels of carcinoembryonic antigen in gallbladder bile compared with serum levels. The aim of this study was to assess the accuracy of bile carcinoembryonic antigen levels taken at the time of operation in predicting patients with occult hepatic metastases. METHODS: Bile and serum carcinoembryonic antigen samples were collected from 37 patients undergoing surgery for colorectal cancer, 26 of whose procedures were deemed curative and who were followed up for a median of 63.5 months. RESULTS: Twelve patients were alive with no evidence of recurrent disease, and two had recurrent disease, whereas 12 died of disease. The median (interquartile range) serum carcinoembryonic antigen in the disease-free group was 2.8 (1.1–6.1) ng/ml, and in the recurrent group it was 6.35 (4.3–30) ng/ml (P=0.006), whereas bile carcinoembryonic antigen in the disease-free group was 7 (5–39) ng/ml as compared with 31 (5–383.7) ng/ml in the recurrent group (P=0.210). The accuracy of serum carcinoembryonic antigen in predicting occult hepatic metastases was 77 percent compared with 72 percent for bile carcinoembryonic antigen. CONCLUSION: Intraoperative bile carcinoembryonic antigen levels are no more accurate than serum carcinoembryonic antigen levels in predicting occult hepatic metastases in patients undergoing potentially curative colorectal cancer surgery.Supported by a grant from The Scottish Home and Health Department.     

Surgery for multiple hepatic colorectal metastases

The purpose of this review is to address three important questions concerning hepatic resection for multiple colorectal metastases. (1) Is the number of tumors truly a significant prognostic factor? (2) Are patients with four or more tumors contraindicated for hepatic resection? (3) Up to how many nodules should we attempt to resect? Although the efficacy of surgical resection for one to three hepatic metastases is clear, based on several reports, the literature regarding the resection of four or more metastatic lesions is conflicting. Review of the data at our institutions showed that the number of tumors was a significant prognostic factor, because patient survival after liver resection for multiple metastases was worse than that for single metastasis. However, patients with two or three nodules and those with four or more nodules showed the same survival curves, or those with four or more metastases fared even better. Therefore, patients with four or more metastases should be considered for hepatic resection. The maximum number of hepatic tumors in longterm survivors reported in the literature has been increasing, and the limit for the number of respectable metastases has not yet been determined. Because liver resection is still the only treatment that offers a cure, surgery for multiple metastases may be justified as long as the operation is safe and technically feasible.